1. Abstract
Impact of the National Healthcare Reform on Prescribing Patterns of Promotional Targeted Drugs among Thai Physicians
Layton MR*, Chadbunchachai S*,Thinkhamrop B**,Tangcharoensathien V***
*Faculty of Pharmaceutical Sciences, Khon Kaen University, Thailand.
**Faculty of Public Health, Khon Kaen University, Thailand.
***International Health Policy Program, Ministry of Public Health, Thailand.
Problem Statement: Worldwide, the 1990’s witnessed the introduction of many promotional targeted drugs (PTD). Despite the fact that these newer drugs have been rapidly adopted in the global therapeutic practice, little is known about the prescribing patterns of PTD among Thai physicians, especially since the enactment of the national health care reform.
Objective: To assess the impact of the reform on prescribing patterns of PTDs among Thai physicians at a teaching hospital.
Design: Retrospective outpatient prescription records of PTDs between 1998 – 2003 were reviewed and compared with data of the established drugs in their respective categories. In addition, a qualitative study on how the PTD were enlisted in the hospital formulary was incorporated. The study was approved by the Institutional Review Board, Khon Kaen University.
Setting: Outpatient department at a teaching hospital in Thailand.
Study Population: Based on the PTD definition stated in the inclusion criteria, two new drugs – a Statin (PTD-M1) and a COX-2 inhibitor (PTD-O1) were identified as PTDs. The electronic outpatient dispensing data from the pharmacy department were retrieved. Qualitative data from in-depth interviews with the secretary team of the Pharmacy & Therapeutic Committee (PTC) including documents on the PTD drug approval process were also assembled.
Outcome measures: The data of both PTDs and related drugs on daily dose prescribed, total numbers of prescriptions and days supplied, total sales volume and value, payment scheme, and descriptive information on the PTC approval process were compared with the respective prescribing departments.
Results: The data of both PTDs showed significant increases in drug use even after the new healthcare policy was enacted. The majority of the drug costs was cash payment - either paid out-of-pocket by the patients or by other reimbursable insurance schemes. While there was evidence that many physicians complied with the cost containment policy, the data also reflected that some of the PTC’s prescribing restrictions were commonly violated.
Conclusion: This exploratory study at a teaching and training hospital reveals an urgent need for further in-depth investigation on critical factors influencing physician prescribing behavior of a promoted drug. Ultimately, it may be necessary to consider any practical policies to curb the escalating drug cost and promote rational drug use in the country.

2. Background & Significance
The 1990’s witnessed the introduction of many promotional targeted drugs (PTD) worldwide with visibly increasing promotional budget
In October 2001, the Universal Coverage Reform was enacted and viewed as a threat to the pharmaceutical market, especially to the global-branded industry
Some prescribing restrictions such as requirement of authorized physicians’ signatures and license no., only designated list of specialists
In 2003, Thailand Total Pharmaceutical Market Value was 44,800 M.Baht (+13% growth), which the market shares of the global and local brands in the medical channel were 67% (+21%growth) and 33% (+9%), respectively

3. Objective
To assess the impact of health care reform on PTD prescribing pattern among Thai physicians at a teaching school hospital where the training site & modeling for the future doctors’ prescribing pattern is located
Based on the PTD inclusion criteria (ie. Relatively new and launched in both global and Thai markets, Global-branded product, Expensive,Visible/known promotional activities, Potentially cause some drug-related problems),
a Statin (PTD-M1) and a COX-2 inhibitor (PTD-O1) were identified as PTDs

4. Methods
A retrospective review of electronic outpatient prescription records of the PTDs at a teaching hospital in Thailand before and after the enactment of the national healthcare reform was examined and compared with data of the established drugs in their respective categories e.g. (O2-Branded, M2-Branded, and M3-Generic)
In addition, in-depth interviews with the secretary team of the Pharmacy & Therapeutic Committee (PTC) including documents on the PTD drug approval process were also assembled
Approval from both the Institutional Review Board as well as the Director of the hospital were obtained prior to the study

5. Results 1: PTD-O1 and Other COX-2 Inhibitors
PTD - O O2
Date of PTC approval Nov Jul 2000
Duration of data analysis
Drug category Non ED ED
Current unit price 30 Baht Baht
Total no. of prescriptions 1, ,902
Total sales volume (Tab/Cap) 84, ,049
Total sales value (Baht) 1,830, ,601,125
Average daily dose prescribed (Tab/Cap)
Avg. quantity prescribed / visit
Avg. no. of days supplied
Avg. price per prescription 1,
Payment type:
Cash % %
Social Security 3.4% %
30 Baht Scheme 0.2% %
CSMBS % %
Others %

6. Figure 1: Total Sales Value of Cox-2 (2000-2003)฿ 50 ,
000
100
150
200
250
300
350
JAN
2000
Apr
Jul
Oct
Jan
2001
2002
2003
Months/Years
PTD – O 1
O 2
Sales Value (Baht)
October 2001: Starting Healthcare Reform

7. Results 2: PTD-M1 and Other Statins
PTD - M M M3
20mg mg mg
Date of PTC approval / / /2001
Duration of data analysis
Drug category ED ED ED
Current unit price Baht Baht Baht
Total no. of prescriptions 5,556 9, ,690
Total sales volume , , ,779,044
Total sales value M M M
Average daily mg prescribed ,301.5
Avg. quantity per visit
Avg. no. of days supplied
Avg. price per prescription , ,
Payment type:
Cash % % %
Social Security % % %
30 Baht Scheme % % %
CSMBS % % %
Others % %

8. Figure 2: Total Sales Value of Statins (1998 – 2003)
Baht ) ฿
100 ,
000
200
300
400
500
600
700
Year M2 M3
PTD-M1
1998
1999
2000
2001
2002
2003
October 2001: Starting Health Care Reform

9. Figure 3: Ratio of Adjusted Sales Volume PTD-O1 to O2 (2001-2003)10 20 30 40 50 60 70 80 90
Ratio to O-2
Trend line of
PTD-O1 to O2
Figure 4: Ratio of Adjusted Sales Volume PTD-M1 to M2 & M3
( )
0.2
0.5 5 10 15
Aug
2000
Nov
Feb
2001
May
2002
2003
Ratio to M2
Ratio to M3
Trend line of M3
Trend line of M2

10. Summary
Both of the observed PTDs showed significant increases in drug use even after the new healthcare policy was enacted.
Except comparing with the generic ED, the PTDs showed higher rate of sales off take than the traditional existing drugs
The majority of the drug costs were cash payment and CSMBS ie. either paid out-of-pocket by the patients or by other reimbursable insurance schemes, thus could be burdensome to the society as a whole
While there was evidence that many physicians complied with the hospital’s cost containment policy, the data also reflected that some of the PTC’s prescribing restrictions were commonly violated

11. Limitation & Discussion
An exploratory study at only one site, a teaching hospital in Thailand. Other setting ie. Regional and Private hospitals may reflect different outcomes due to different nature of both patients and hospital policy management
Using OPD dispensing data at the hospital pharmacy only with lack of records on prescribers and diagnosis

12. Conclusion & Implication
Various marketing strategies and promotional efforts have been successfully exercised by multinational companies to sustain the drug product life cycle even facing the market threat like the national healthcare reform
Out of pocket payment by UC members for ambulatory care is not uncommon if UC beneficiaries perceived low quality of generic products
It may be critical to consider any practical policies to curb the drug cost and promote rational drug use in the country